Study on how Medicaid patients use services adds fuel to debate

New members found to visit emergency rooms 40 percent more often

Jan. 8, 2014

Registered nurse Kate Reiff walks through the emergency room at Vanderbilt Hospital last year. A recent study found that people with new Medicaid coverage used the emergency department, on average, 40 percent more than a control group. / George Walker IV / File / The Tennessean

Written by

Shelley DuBois

The Tennessean

FROM THE STUDY

» Patients with Medicaid made, on average, 1.43 ER visits, compared with 1.02 for those who lost the lottery for Medicaid coverage, an increase of 40 percent. » Men were more likely than women to have additional ER visits, but there was no racial, age or other groups that saw a statistically significant decrease in ER usage among the people selected for Medicaid. » ER visits increased both during nights and weekends and during typical business hours, when ER alternatives would generally be open. » The additional visits were exclusively outpatient, and many of the Medicaid patients were diagnosed with conditions that could have been treated in a primary-care office.

— Associated Press

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A recent study published in Science has added fuel to the heated debate about Medicaid expansion and its effect on our health care system. A team, including researchers at The National Bureau of Economic Research in Massachusetts, published the results from its investigation of how new Medicaid members use a variety of services, including emergency care.

Emergency care statistics can be controversial because much of the national dialogue about reducing the cost of health care involves routing people out of the emergency room and into primary care doctors’ offices or nurse-run clinics, whenever possible.

The tinderbox stat from the Science study was this: Over the 18 months that researchers collected the data, the people with new Medicaid coverage used the emergency department, on average, 40 percent more than the control group. Those visits included trips for conditions that could have been treated outside of the ER, the study said.

Having a control group at all in a study like this is important. To get a controlled study, the researchers followed a specific situation in Oregon, which expanded its Medicaid eligibility in 2008, long before the Affordable Care Act was in play. The state saw such massive demand that it set up a lottery system for potential new members — some people got the expanded coverage, some didn’t.

That setup enabled researchers to review data from two groups of people who visited a handful of hospitals in the Portland area — one group of Medicaid-eligible people who were covered, and a similar group that wasn’t covered.

Data not so shocking

The study certainly shows how difficult it is to set up a controlled health care study, despite the growing need for this kind of research. But the emergency department usage data, while important, are not so shocking.

See, along with emergency department visits, the study showed, new Medicaid members used all kinds of services, including preventative care and prescription drugs. “We see increases in a lot of types of use,” said Sarah Taubman, a research fellow at The National Bureau of Economic Research and a lead author on the study. “If the price of something is lower, people will use more of it.”

Also important to note: The study didn’t track whether new Medicaid members were consulted about primary care or outpatient clinics. It seems simple, but people won’t use a lower-cost service if they don’t know it exists.

Unfortunately, providing low-cost care doesn’t always line up with financial incentives for providers. For example, while this study shows that Medicaid access boosted annual spending for emergency departments at these hospitals, it does not take into account the hospitals’ financial health. The truth is, providers probably made good money off of the ER visits. ER visits hurt the hospital financially only if patients are uninsured or don’t pay, but in this case, Medicaid would have covered much of the cost.

Hospitals everywhere have seen a trend of more emergency department visits, whether or not their states expanded Medicaid.

Modern Healthcare reported that, according to data from the American Hospital Association’s statistics guide, emergency department visits in the 2012 fiscal year increased by 2.9 percent compared with the previous year, even though overall admissions had declined. That didn’t hurt earnings too much: Net revenue at hospitals jumped from $755.3 billion in 2011 to $821.3 billion in 2012.

Those are big-picture numbers, and the Science study is small and targeted. But going forward, all good data will be useful, in context, as the country tries to figure out how to pay for services that provide better care for more people. And no one should be surprised when people use services that are cheap or free.